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<body>
<p align="center" class="style1 style1"> FORMULIR PENDATAAN CALON SISWA BARU </p>
<p align="center" class="style1"><strong>SDIT LUQMAN AL HAKIM YOGYAKARTA</strong></p>
<p align="center" class="style1"><strong>TAHUN AJARAN 2009/2010 </strong></p>
<p class="style1">&nbsp;</p>
<table width="200" border="1" align="left">
  <tr>
    <td><em>*Form 1 Pendaftaran </em><strong>-1/2-</strong></td>
  </tr>
</table>
<p>&nbsp;</p>
<p>&nbsp;</p>
<?php echo form_open('kesiswaan/pendaftaran')?>
<?php echo validation_errors(); ?>
<table border="1" align="center">
  <tbody>
    <tr>
      <td colspan="2"><strong>A. DATA CALON SISWA</strong></td>
    </tr>
    <tr>
      <td width="242">No. Pendaftaran </td>
      <td width="795" valign="top"><?php echo form_input('no_pendaftaran', set_value('no_pendaftaran'))?></td>
    </tr>
    <tr>
      <td>Nama Lengkap</td>
      <td valign="top"><?php echo form_input('nama_lengkap', set_value('nama_lengkap'), 'size="50"')?>
      <?php form_error('nama_lengkap')?></td>
    </tr>
    <tr>
      <td>Nama Panggilan </td>
      <td valign="top"><?php echo form_input('nama_panggilan', set_value('nama_panggilan'))?></td>
    </tr>
    <tr>
      <td>Jenis Kelamin </td>
      <td valign="top"><form id="form1" name="form1" method="post" action="">
      <?php echo form_radio('jenis_kelamin', 'L')?><label> Laki-laki</label>
      <?php echo form_radio('jenis_kelamin', 'P')?><label> Perempuan</label></td>
    </tr>
    <tr>
      <td>Tempat, Tanggal Lahir</td>
      <td valign="top"><?php echo form_input('tempat_lahir', set_value('tempat_lahir'))?>
        ,
       <select name="txt_tanggal">
            <option selected="selected" value="">Pilih</option>
            <?for ($i=1;$i<32;$i++) {?>
               <option value="<?=$i?>"><?=$i?></option>
            <?}?>
        </select>
        -
        <select name="txt_bulan">
          <option selected="selected" value="">Pilih</option>
          <option value="1">Januari</option>
          <option value="2">Februari</option>
          <option value="3">Maret</option>
          <option value="4">April</option>
          <option value="5">Mei</option>
          <option value="6">Juni</option>
          <option value="7">Juli</option>
          <option value="8">Agustus</option>
          <option value="9">September</option>
          <option value="10">Oktober</option>
          <option value="11">November</option>
          <option value="12">Desember</option>
        </select>
        -
        <input name="txt_tahun" size="15" type="text" /></td>
    </tr>
    <tr>
      <td>Alamat Tinggal Sekarang</td>
      <td valign="top"><input name="txt_alamatsekarang" size="110" type="text" /></td>
    </tr>
    <tr>
      <td></td>
      <td valign="top"><table width="642" border="0">
          <tr>
            <td width="102">Desa/Kelurahan</td>
            <td width="123"><input name="txt_alamatsekarang4" size="20" type="text" /></td>
            <td width="76">Kecamatan</td>
            <td width="124"><input name="txt_alamatsekarang2" size="20" type="text" /></td>
            <td width="68">Kabupaten</td>
            <td width="123"><input name="txt_alamatsekarang3" size="20" type="text" /></td>
          </tr>
          <tr>
            <td>Kode/Pos</td>
            <td><input name="txt_alamatsekarang42" size="20" type="text" /></td>
            <td>No.Telp/HP</td>
            <td><input name="txt_alamatsekarang22" size="20" type="text" /></td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
        </table>        </td>
    </tr>
    <tr>
      <td height="34">Tinggi Badan </td>
      <td valign="top"><table width="638" border="0">
          <tr>
            <td width="60" height="26"><input name="txt_alamatsekarang43" size="10" type="text" /></td>
            <td width="38">cm,</td>
            <td width="108">Berat Badan </td>
            <td width="66"><input name="txt_alamatsekarang44" size="10" type="text" /></td>
            <td width="37">kg,</td>
            <td width="110">Golongan Darah </td>
            <td width="173"><input name="txt_alamatsekarang442" size="10" type="text" /></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td>Penyakit yang sedang di derita</td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Penyakit yang pernah di derita </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Jumlah Saudara Kandung </td>
      <td valign="top"><table width="793" border="0">
        <tr>
          <td width="115" height="24"><input name="txt_alamatsekarang432" size="10" type="text" />
            ,</td>
          <td width="180">Anak Tersebut Nomor </td>
          <td width="106"><input name="txt_alamatsekarang443" size="10" type="text" />
            ,</td>
          <td width="303">Jumlah Sdr. Kandung yang masih di SDIT </td>
          <td width="67"><input name="txt_alamatsekarang4422" size="10" type="text" /></td>
        </tr>
      </table></td>
    </tr>
    <tr>
      <td height="32">Jumlah Saudara Tiri </td>
      <td valign="top"><table width="794" border="0">
        <tr>
          <td width="115" height="26"><input name="txt_alamatsekarang432" size="10" type="text" />
            ,</td>
          <td width="186">Jumlah Saudara Angkat </td>
          <td width="100"><input name="txt_alamatsekarang443" size="10" type="text" />
            ,</td>
          <td width="62">Nama</td>
          <td width="309"><input name="txt_alamatsekarang4422" size="50" type="text" /></td>
        </tr>

      </table></td>
    </tr>
    <tr>
      <td height="32">&nbsp;</td>
      <td valign="top"><table width="795" border="0">
          <tr>
            <td width="474" height="26">&nbsp;</td>
            <td width="311"><input name="txt_alamatsekarang4422" size="50" type="text" /></td>
          </tr>
      </table></td>
    </tr>
    <tr>
      <td>Jarak Rumah ke Sekolah </td>
      <td valign="top"><input name="txt_alamatasal" size="10" type="text" />
        km </td>
    </tr>
    <tr>
      <td>Kemampuan Membaca </td>
      <td valign="top">&nbsp;</td>
    </tr>
    <tr>
      <td>&nbsp;</td>
      <td valign="top"><table width="433" border="0">
        <tr>
          <td width="93">1. Latin : </td>
          <td width="324"><input name="txt_gender" value="L" type="radio" />
Lancar
  <input name="txt_gender" value="P" type="radio" />
Sedikit-sedikit
<input name="txt_gender" value="L" type="radio" />
Belum Bisa</td>
        </tr>
      </table>      </td>
    </tr>
    <tr>
      <td>&nbsp;</td>
      <td valign="top"><table width="433" border="0">
        <tr>
          <td width="93">2. Arab : </td>
          <td width="324"><input name="txt_gender" value="L" type="radio" />
            Lancar
            <input name="txt_gender" value="P" type="radio" />
            Sedikit-sedikit
            <input name="txt_gender" value="L" type="radio" />
            Belum Bisa</td>
        </tr>
      </table></td>
    </tr>
    <tr>
      <td>Kebiasaan Belajar </td>
      <td valign="top"><input name="txt_gender" value="L" type="radio" />
        Sudah Biasa
          <input name="txt_gender" value="P" type="radio" />
        Susah
        <input name="txt_gender" value="L" type="radio" />
        Belum Biasa </td>
    </tr>
    <tr>
      <td>Sifat yang Menonjol </td>
      <td valign="top"><table width="474" border="0">
        <tr>
          <td width="80"><form id="form2" name="form2" method="post" action="">
            <label>
              <input type="checkbox" name="checkbox" value="checkbox" />
              Aktif</label>
          </form>          </td>
          <td width="76"><label>
<input type="checkbox" name="checkbox2" value="checkbox" />
Pemalu</label></td>
          <td width="91"><label>
            <input type="checkbox" name="checkbox3" value="checkbox" />
Pemarah</label></td>
          <td width="209"><form id="form3" name="form3" method="post" action="">
            <label></label>
          atau lainnya
          <input name="txt_alamatasal2" size="15" type="text" />
          </form>          </td>
        </tr>
      </table>      </td>
    </tr>
    <tr>
      <td>Surat Al-Qur'an yang Pernah Dihafal </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Doa Harian yang Pernah Dihafal </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Lama Belajar di TK </td>
      <td valign="top"><input name="txt_alamatasal" size="10" type="text" />
        Tahun</td>
    </tr>
    <tr>
      <td>Prestasi yang Pernah di Raih </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Nama TK </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Alamat TK </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Nama SD (*Khusus Pindahan) </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Alamat SD (*Khusus Pindahan) </td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Kelas</td>
      <td valign="top"><input name="txt_alamatasal" size="50" type="text" /></td>
    </tr>
    <tr>
      <td>Pernah Mendapat Beasiswa </td>
      <td valign="top"><form id="form1" name="form1" method="post" action="">
          <label>
          <input name="txt_gender" value="P" type="radio" />
            Ya</label>
          <label>
          <input name="txt_gender" value="P" type="radio" />
            Tidak</label>
      </form></td>
    </tr>
    <tr>
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr>
      <td></td>
      <td valign="top"><input name="simpan" size="50" type="submit" value="Simpan" />
          <input name="reset" size="50" type="reset" value="Reset" /></td>
    </tr>
  </tbody>
</table>
<?php echo form_close()?>
<p>&nbsp;</p>
<p>&nbsp;</p>
<hr>
<p align="center">
<div align="center">
<p align="center" class="style1"><strong>ADMINISTRATOR PSB INPUT</strong></p>
  <p>&nbsp;</p>
  <p>&nbsp;</p>
  <table width="200" border="1" align="left">
    <tr>
      <td><em>*Form 2 Pendaftaran </em><strong>-2/2-</strong></td>
    </tr>
  </table>
  <p>&nbsp;</p>
  <p>&nbsp;</p>
  <table border="1">
    <tbody>
      <tr>
        <td colspan="2"><strong>B. DATA ORANG TUA </strong></td>
      </tr>
      <tr>
        <td width="241">No. Pendaftaran </td>
        <td width="793" valign="top"><input name="txt_nama2" type="text" /></td>
      </tr>
      <tr>
        <td>Nama Ayah </td>
        <td valign="top"><input name="txt_nama2" type="text" size="50" /></td>
      </tr>
      <tr>
        <td>Nama Ibu </td>
        <td valign="top"><input name="txt_nama2" type="text" size="50" /></td>
      </tr>
      <tr>
        <td>Alamat (*Sesuai KTP) </td>
        <td valign="top"><input name="txt_alamatsekarang5" size="110" type="text" /></td>
      </tr>
      <tr>
        <td></td>
        <td valign="top"><table width="642" border="0">
          <tr>
            <td width="102">Desa/Kelurahan</td>
            <td width="123"><input name="txt_alamatsekarang45" size="20" type="text" /></td>
            <td width="76">Kecamatan</td>
            <td width="124"><input name="txt_alamatsekarang23" size="20" type="text" /></td>
            <td width="68">Kabupaten</td>
            <td width="123"><input name="txt_alamatsekarang32" size="20" type="text" /></td>
          </tr>
          <tr>
            <td>Kode/Pos</td>
            <td><input name="txt_alamatsekarang422" size="20" type="text" /></td>
            <td>No.Telp/HP</td>
            <td><input name="txt_alamatsekarang222" size="20" type="text" /></td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>Pendidikan Orang Tua </td>
        <td valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="692" border="0">
          <tr>
            <td width="94">1. Ayah : </td>
            <td width="588"><input name="txt_gender" value="L" type="radio" />
              SLTP
              <input name="txt_gender" value="P" type="radio" />
              SLTA
              <input name="txt_gender" value="L" type="radio" />
              Diploma
              <input name="txt_gender" value="L" type="radio" />
              S1
              <input name="txt_gender" value="P" type="radio" />
              S2
              <input name="txt_gender" value="L" type="radio" />
              S3</td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="692" border="0">
          <tr>
            <td width="94">2. Ibu : </td>
            <td width="588"><input name="txt_gender" value="L" type="radio" />
              SLTP
              <input name="txt_gender" value="P" type="radio" />
              SLTA
              <input name="txt_gender" value="L" type="radio" />
              Diploma
              <input name="txt_gender" value="L" type="radio" />
              S1
              <input name="txt_gender" value="P" type="radio" />
              S2
              <input name="txt_gender" value="L" type="radio" />
              S3 </td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>Pekerjaan Orang Tua </td>
        <td valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="692" border="0">
          <tr>
            <td width="94">1. Ayah : </td>
            <td width="588"><input name="txt_nama22" type="text" size="50" /></td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="692" border="0">
          <tr>
            <td width="94">2. Ibu : </td>
            <td width="588"><input name="txt_nama23" type="text" size="50" /></td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>Penghasilan Per Bulan </td>
        <td valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="793" border="0">
          <tr>
            <td width="94">1. Ayah : </td>
            <td width="689"><input name="txt_gender" value="L" type="radio" />
              500.000 s/d 1.000.000
              <input name="txt_gender" value="P" type="radio" />
              1.000.000 s/d 2.000.000
              <input name="txt_gender" value="L" type="radio" />
              diatas 2.000.000 </td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="793" border="0">
          <tr>
            <td width="94">2. Ibu : </td>
            <td width="689"><input name="txt_gender" value="L" type="radio" />
              500.000 s/d 1.000.000
              <input name="txt_gender" value="P" type="radio" />
              1.000.000 s/d 2.000.000
              <input name="txt_gender" value="L" type="radio" />
              diatas 2.000.000 </td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td colspan="2">&nbsp;</td>
      </tr>
      <tr>
        <td colspan="2">C. KESEDIAAN PEMBAYARAN SEKOLAH </td>
      </tr>
      <tr>
        <td>Infaq Pengembangan Pendidikan </td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          4.000.000
          <input name="txt_gender" value="P" type="radio" />
          4.500.000
          <input name="txt_gender" value="L" type="radio" />
          5.000.000
          <input name="txt_gender" value="P" type="radio" />
          &gt; 5.000.000 :
          <input name="txt_tahun2" size="20" type="text" /></td>
      </tr>
      <tr>
        <td>Pembayaran</td>
        <td valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="793" border="0">
          <tr>
            <td width="94">1. Waktu : </td>
            <td width="689"><input name="txt_gender" value="L" type="radio" />
              Lunas Saat Daftar Ulang
              <input name="txt_gender" value="P" type="radio" />
              Diangsur Sampai Bulan Oktober 2010 </td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="793" border="0">
          <tr>
            <td>2. Teknis(Bagi yang Mengangsur): </td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><table width="793" border="0">
          <tr>
            <td><table width="780" border="1">
              <tr>
                <td width="305" height="137"><input name="txt_gender" value="L" type="radio" />
                  Rp. 3.000.000,- Saat Buka Rekening </td>
                <td width="459"><p>Angsuran : (isi dengan nominal) </p>
                        <table width="454" border="1">
                          <tr>
                            <td width="97"><div align="center">Juli</div></td>
                            <td width="100"><div align="center">Agustus</div></td>
                            <td width="119"><div align="center">September</div></td>
                            <td width="110"><div align="center">Oktober</div></td>
                          </tr>
                          <tr>
                            <td><div align="center">
                                <input name="txt_tahun3" size="15" type="text" />
                            </div></td>
                            <td><div align="center">
                                <input name="txt_tahun4" size="15" type="text" />
                            </div></td>
                            <td><div align="center">
                                <input name="txt_tahun5" size="15" type="text" />
                            </div></td>
                            <td><div align="center">
                                <input name="txt_tahun6" size="15" type="text" />
                            </div></td>
                          </tr>
                        </table>
                  <p>&nbsp;</p></td>
              </tr>
              </table></td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td>Biaya Rutin Tiap Bulan</td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          300.000
          <input name="txt_gender" value="P" type="radio" />
          325.000
          <input name="txt_gender" value="L" type="radio" />
          350.000
          <input name="txt_gender" value="P" type="radio" />
          &gt; 350.000 :
          <input name="txt_tahun2" size="20" type="text" /></td>
      </tr>
      <tr>
        <td>Biaya Seragam Jadi</td>
        <td rowspan="2" valign="top"><input name="txt_gender" value="L" type="radio" />
          Putra : Rp. 490.000,-
          <input name="txt_gender" value="P" type="radio" />
          Putri : Rp. 570.000,- </td>
      </tr>
      <tr>
        <td>(5 stel + Tas Logo + Topi + Dasi) </td>
      </tr>
      <tr>
        <td colspan="2">&nbsp;</td>
      </tr>
      <tr>
        <td colspan="2">D. LAIN-LAIN</td>
      </tr>
      <tr>
        <td>Rencana Pergi Sekolah </td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          Ikut Antar Jemput
          <input name="txt_gender" value="P" type="radio" />
          Diantar Orang Tua
          <input name="txt_gender" value="L" type="radio" />
          Berangkat Sendiri </td>
      </tr>
      <tr>
        <td>Alasan Menyekolahkan ke SDIT LH</td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          Karena Full Day School
          <input name="txt_gender" value="P" type="radio" />
          Orang Tua Sibuk
          <input name="txt_gender" value="L" type="radio" />
          Meneruskan dari TK IT </td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          Mendapatkan Ilmu Agama dan Umum
          <input name="txt_gender" value="L" type="radio" />
          Lainnya :
          <input name="txt_tahun7" size="15" type="text" /></td>
      </tr>
      <tr>
        <td>Informasi SDIT LH </td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          Dari Teman
          <input name="txt_gender" value="P" type="radio" />
          Brosur
          <input name="txt_gender" value="L" type="radio" />
          Media Massa
          <input name="txt_gender" value="L" type="radio" />
          Kakaknya di SDIT LH</td>
      </tr>
      <tr>
        <td>Harapan Pasca SDIT LH </td>
        <td valign="top"><input name="txt_gender" value="L" type="radio" />
          SMP IT
          <input name="txt_gender" value="P" type="radio" />
          PONPES
          <input name="txt_gender" value="L" type="radio" />
          SMP NEGERI
          <input name="txt_gender" value="L" type="radio" />
          SMP LAINNYA </td>
      </tr>
      <tr>
        <td>Harapan Untuk SDIT LH </td>
        <td valign="top"><input name="txt_alamatasal3" size="100" type="text" /></td>
      </tr>
      <tr>
        <td colspan="2">&nbsp;</td>
      </tr>
      <tr>
        <td></td>
        <td valign="top"><input name="simpan2" size="50" type="submit" value="Simpan" />
            <input name="reset2" size="50" type="reset" value="Reset" /></td>
      </tr>
    </tbody>
  </table>
</div>
<p>&nbsp;</p>
<hr>
<p align="center" class="style2">&nbsp;</p>
<div align="center">
  <table width="507" border="1" align="left">
    <tr>
      <td width="59" rowspan="3"><span class="style2">NB :</span></td>
      <td width="432"><span class="style2">*Wajib diisi lengkap (sebagai syarat administratif)</span></td>
    </tr>
    <tr>
      <td><span class="style2">*Lembar -1 Untuk bagian Tata Usaha</span></td>
    </tr>
    <tr>
      <td><span class="style2">*Lembar -2 Untuk orang tua </span></td>
    </tr>
  </table>
</div>
</body>
